Surgical instrument with spot coagulation control and algorithm

ABSTRACT

A surgical instrument includes an end effector that has an ultrasonic blade and a clamp arm that is movable relative to the ultrasonic blade from an opened position toward a closed position. The ultrasonic blade and the clamp arm are able to receive tissue in the opened position, and the clamp arm is able to clamp tissue against the ultrasonic blade in the closed position. There is a first electrode connected with the clamp arm, and a second electrode associated with the ultrasonic blade. The electrodes are able to apply bipolar radiofrequency (RF) energy to tissue captured in the end effector. The instrument further has a first button for activating the ultrasonic blade to provide a cutting and sealing mode at the end effector. There is also a second button for activating the electrodes to provide a spot coagulation mode at the end effector.

PRIORITY

This application claims priority to: (1) U.S. Provisional PatentApplication Ser. No. 62/422,698, filed Nov. 16, 2016, entitled“Ultrasonic Surgical Shears with Contained Compound Lever Clamp ArmActuator,” the disclosure of which is incorporated by reference herein;(2) U.S. Provisional Patent Application Ser. No. 62/508,720, filed May19, 2017, entitled “Ultrasonic and Electrosurgical Instrument withReplaceable End Effector Features,” the disclosure of which isincorporated by reference herein; and (3) U.S. Provisional PatentApplication Ser. No. 62/519,482, filed Jun. 14, 2017, entitled“Ultrasonic and Electrosurgical Instrument with Removable Features,” thedisclosure of which is incorporated by reference herein.

BACKGROUND

A variety of surgical instruments include an end effector having a bladeelement that vibrates at ultrasonic frequencies to cut and/or sealtissue (e.g., by denaturing proteins in tissue cells). These instrumentsinclude piezoelectric elements that convert electrical power intoultrasonic vibrations, which are communicated along an acousticwaveguide to the blade element. The precision of cutting and coagulationmay be controlled by the surgeon's technique and adjusting the powerlevel, blade edge, tissue traction and blade pressure.

Examples of ultrasonic surgical instruments include the HARMONIC ACE®Ultrasonic Shears, the HARMONIC WAVE® Ultrasonic Shears, the HARMONICFOCUS® Ultrasonic Shears, and the HARMONIC SYNERGY® Ultrasonic Blades,all by Ethicon Endo-Surgery, Inc. of Cincinnati, Ohio. Further examplesof such devices and related concepts are disclosed in U.S. Pat. No.5,322,055, entitled “Clamp Coagulator/Cutting System for UltrasonicSurgical Instruments,” issued Jun. 21, 1994, the disclosure of which isincorporated by reference herein; U.S. Pat. No. 5,873,873, entitled“Ultrasonic Clamp Coagulator Apparatus Having Improved Clamp Mechanism,”issued Feb. 23, 1999, the disclosure of which is incorporated byreference herein; U.S. Pat. No. 5,980,510, entitled “Ultrasonic ClampCoagulator Apparatus Having Improved Clamp Arm Pivot Mount,” filed Oct.10, 1997, the disclosure of which is incorporated by reference herein;U.S. Pat. No. 6,325,811, entitled “Blades with Functional BalanceAsymmetries for use with Ultrasonic Surgical Instruments,” issued Dec.4, 2001, the disclosure of which is incorporated by reference herein;U.S. Pat. No. 6,773,444, entitled “Blades with Functional BalanceAsymmetries for Use with Ultrasonic Surgical Instruments,” issued Aug.10, 2004, the disclosure of which is incorporated by reference herein;and U.S. Pat. No. 6,783,524, entitled “Robotic Surgical Tool withUltrasound Cauterizing and Cutting Instrument,” issued Aug. 31, 2004,the disclosure of which is incorporated by reference herein.

Still further examples of ultrasonic surgical instruments are disclosedin U.S. Pub. No. 2006/0079874, entitled “Tissue Pad for Use with anUltrasonic Surgical Instrument,” published Apr. 13, 2006, the disclosureof which is incorporated by reference herein; U.S. Pub. No.2007/0191713, entitled “Ultrasonic Device for Cutting and Coagulating,”published Aug. 16, 2007, the disclosure of which is incorporated byreference herein; U.S. Pub. No. 2007/0282333, entitled “UltrasonicWaveguide and Blade,” published Dec. 6, 2007, the disclosure of which isincorporated by reference herein; U.S. Pub. No. 2008/0200940, entitled“Ultrasonic Device for Cutting and Coagulating,” published Aug. 21,2008, the disclosure of which is incorporated by reference herein; U.S.Pat. No. 8,623,027, entitled “Ergonomic Surgical Instruments,” issuedJan. 7, 2014, the disclosure of which is incorporated by referenceherein; U.S. Pat. No. 9,023,071, entitled “Ultrasonic Device forFingertip Control,” issued May 5, 2015, the disclosure of which isincorporated by reference herein; and U.S. Pat. No. 8,461,744, entitled“Rotating Transducer Mount for Ultrasonic Surgical Instruments,” issuedJun. 11, 2013, the disclosure of which is incorporated by referenceherein; and U.S. Pat. No. 8,591,536, entitled “Ultrasonic SurgicalInstrument Blades,” issued Nov. 26, 2013, the disclosure of which isincorporated by reference herein.

Some of ultrasonic surgical instruments may include a cordlesstransducer such as that disclosed in U.S. Pat. No. 9,381,058, entitled“Recharge System for Medical Devices,” issued Jul. 5, 2016, thedisclosure of which is incorporated by reference herein; U.S. Pub. No.2012/0116265, entitled “Surgical Instrument with Charging Devices,”published May 10, 2012, the disclosure of which is incorporated byreference herein; and/or U.S. Pat. App. No. 61/410,603, filed Nov. 5,2010, entitled “Energy-Based Surgical Instruments,” the disclosure ofwhich is incorporated by reference herein.

Additionally, some ultrasonic surgical instruments may include anarticulating shaft section. Examples of such ultrasonic surgicalinstruments are disclosed in U.S. Pat. No. 9,393,037, entitled “SurgicalInstruments with Articulating Shafts,” issued Jul. 19, 2016, thedisclosure of which is incorporated by reference herein; and U.S. Pat.No. 9,095,367, entitled “Flexible Harmonic Waveguides/Blades forSurgical Instruments,” issued Aug. 4, 2015 the disclosure of which isincorporated by reference herein.

While several surgical instruments and systems have been made and used,it is believed that no one prior to the inventors has made or used theinvention described in the appended claims.

BRIEF DESCRIPTION OF THE DRAWINGS

While the specification concludes with claims which particularly pointout and distinctly claim this technology, it is believed this technologywill be better understood from the following description of certainexamples taken in conjunction with the accompanying drawings, in whichlike reference numerals identify the same elements and in which:

FIG. 1A depicts a perspective view of a first exemplary surgicalinstrument, with an end effector of the instrument in an openconfiguration;

FIG. 1B depicts a perspective view of the instrument of FIG. 1A, withthe end effector in a closed configuration;

FIG. 2 depicts an exploded perspective view of the instrument of FIG.1A;

FIG. 3 depicts a perspective view of a first modular assembly of theinstrument of FIG. 1A;

FIG. 4 depicts a perspective view of the first modular assembly of FIG.3, with selected portions purposefully omitted for clarity;

FIG. 5 depicts a perspective view of a shaft assembly and a bladeassembly of the first modular assembly of FIG. 3;

FIG. 6 depicts a cross-sectional perspective view of the shaft assemblyand blade assembly of FIG. 5;

FIG. 7 depicts a perspective view of a coupling member of the instrumentof FIG. 1A;

FIG. 8 depicts a perspective view of a second modular assembly of theinstrument of FIG. 1A;

FIG. 9 depicts an exploded perspective view of the second modularassembly of FIG. 8;

FIG. 10 depicts an exploded perspective view of a clamp arm assembly anda clamp pad assembly of the second modular assembly of FIG. 8;

FIG. 11 depicts a perspective view of the clamp arm assembly of FIG. 10;

FIG. 12 depicts a cross-sectional side view of the clamp arm assembly ofFIG. 10, taken along line 12-12 of FIG. 11;

FIG. 13A depicts a perspective view of the second modular assembly ofFIG. 8 aligned with the shaft assembly of FIG. 5 in order to couple themodular assemblies together;

FIG. 13B depicts a perspective view of the second modular assembly ofFIG. 8 inserted over the shaft assembly of FIG. 5;

FIG. 13C depicts a perspective view of the second modular assembly ofFIG. 8 coupled with the shaft assembly of FIG. 5 via the coupling memberof FIG. 7;

FIG. 14A depicts a cross-sectional side view of the second modularassembly of FIG. 8 partially inserted over the shaft assembly of FIG. 5,taken along line 14-14 of FIG. 13B;

FIG. 14B depicts a cross-sectional side view of the second modularassembly of FIG. 8 further inserted over the shaft assembly of FIG. 5,taken along line 14-14 of FIG. 13B;

FIG. 14C depicts a cross-sectional side view of the second modularassembly of FIG. 8 inserted over the shaft assembly of FIG. 5 while thecoupling member of FIG. 7 is rotated toward a configuration to couplethe shaft assembly with the second modular assembly, taken along line14-14 of FIG. 13B;

FIG. 14D depicts a cross-sectional side view of the coupling member ofFIG. 7 connecting the second modular assembly of FIG. 8 and the shaftassembly of FIG. 5, taken along line 14-14 of FIG. 13B;

FIG. 15A depicts a cross-sectional front view of the second modularassembly of FIG. 8 inserted over the shaft assembly of FIG. 5, takenalong line 15A-15A of FIG. 14B;

FIG. 15B depicts of cross-sectional front view of the second modularassembly of FIG. 8 inserted over the shaft assembly of FIG. 5 while thecoupling member of FIG. 7 is rotated toward a configuration to couplethe shaft assembly with the second modular assembly, taken along line15B-15B of FIG. 14C;

FIG. 15C depicts a cross-sectional front view of the coupling member ofFIG. 7 connecting the second modular assembly of FIG. 8 and the shaftassembly of FIG. 5, taken along line 15C-15C of FIG. 14D;

FIG. 16A depicts a cross-sectional side view of the second modularassembly of FIG. 8 coupled with the shaft assembly of FIG. 5, where theend effector is in an open configuration;

FIG. 16B depicts a cross-sectional side view of the second modularassembly of FIG. 8 coupled with the shaft assembly of FIG. 5, where theend effector is in a closed configuration;

FIG. 17 depicts a perspective view of a second exemplary surgicalinstrument, with an end effector of the instrument in an openconfiguration;

FIG. 18 depicts a partially exploded perspective view of the instrumentof FIG. 17;

FIG. 19 depicts a partial perspective view of the distal end of a clamparm actuator of the instrument of FIG. 17;

FIG. 20 depicts a perspective view of a shaft assembly and ultrasonicblade of the instrument of FIG. 17;

FIG. 21 depicts a perspective view of a removable clamp arm assembly ofthe instrument of FIG. 17;

FIG. 22 depicts an exploded perspective view of the clamp arm assemblyof FIG. 21;

FIG. 23 depicts a partial perspective view of a proximal end of a clamparm body of the clamp arm assembly of FIG. 22;

FIG. 24 depicts a partial perspective view of a third exemplary surgicalinstrument including an exemplary handle body, with the handle bodyincluding a deactivation button;

FIG. 25 depicts a partial perspective view of the surgical instrument ofFIG. 24, with an exemplary end effector in an open position andincluding a clamp arm and an ultrasonic blade, the clamp arm includingtwo poles and the ultrasonic blade including one pole;

FIG. 26 depicts a partial perspective view of the handle body of FIG.24, with the button engaged by a clamp arm actuator;

FIG. 27 depicts a partial perspective view of the end effector of FIG.25, with the end effector in an intermediate position;

FIG. 28 depicts a partial perspective view of the clamp arm of FIG. 25,with the two poles positioned therein and separately spaced;

FIG. 29 depicts a partial perspective view of the clamp arm of FIG. 25;and

FIG. 30 depicts a diagrammatical view of a method of coagulation.

The drawings are not intended to be limiting in any way, and it iscontemplated that various embodiments of the technology may be carriedout in a variety of other ways, including those not necessarily depictedin the drawings. The accompanying drawings incorporated in and forming apart of the specification illustrate several aspects of the presenttechnology, and together with the description serve to explain theprinciples of the technology; it being understood, however, that thistechnology is not limited to the precise arrangements shown.

DETAILED DESCRIPTION

The following description of certain examples of the technology shouldnot be used to limit its scope. Other examples, features, aspects,embodiments, and advantages of the technology will become apparent tothose skilled in the art from the following description, which is by wayof illustration, one of the best modes contemplated for carrying out thetechnology. As will be realized, the technology described herein iscapable of other different and obvious aspects, all without departingfrom the technology. Accordingly, the drawings and descriptions shouldbe regarded as illustrative in nature and not restrictive.

It is further understood that any one or more of the teachings,expressions, embodiments, examples, etc. described herein may becombined with any one or more of the other teachings, expressions,embodiments, examples, etc. that are described herein. Thefollowing-described teachings, expressions, embodiments, examples, etc.should therefore not be viewed in isolation relative to each other.Various suitable ways in which the teachings herein may be combined willbe readily apparent to those of ordinary skill in the art in view of theteachings herein. Such modifications and variations are intended to beincluded within the scope of the claims.

For clarity of disclosure, the terms “proximal” and “distal” are definedherein relative to a human or robotic operator of the surgicalinstrument. The term “proximal” refers the position of an element closerto the human or robotic operator of the surgical instrument and furtheraway from the surgical end effector of the surgical instrument. The term“distal” refers to the position of an element closer to the surgical endeffector of the surgical instrument and further away from the human orrobotic operator of the surgical instrument. In addition, the terms“upper,” “lower,” “lateral,” “transverse,” “bottom,” and “top” arerelative terms to provide additional clarity to the figure descriptionsprovided below. The terms “upper,” “lower,” “lateral,” “transverse,”“bottom,” and “top” are thus not intended to unnecessarily limit theinvention described herein.

I. FIRST EXEMPLARY ULTRASONIC SURGICAL INSTRUMENT FOR OPEN SURGICALPROCEDURES

FIGS. 1A-2 and FIGS. 13A-13C illustrate a first exemplary ultrasonicsurgical instrument (10). At least part of instrument (10) may beconstructed and operable in accordance with at least some of theteachings of U.S. Pat. No. 5,322,055; U.S. Pat. No. 5,873,873; U.S. Pat.No. 5,980,510; U.S. Pat. No. 6,325,811; U.S. Pat. No. 6,773,444; U.S.Pat. No. 6,783,524; U.S. Pub. No. 2006/0079874; U.S. Pub. No.2007/0191713; U.S. Pub. No. 2007/0282333; U.S. Pub. No. 2008/0200940;U.S. Pat. No. 8,623,027; U.S. Pat. No. 9,023,071; U.S. Pat. No.8,461,744; U.S. Pat. No. 9,381,058; U.S. Pub. No. 2012/0116265; U.S.Pat. No. 9,393,037; U.S. Pat. No. 9,095,367; U.S. Pat. App. No.61/410,603; and/or U.S. Pub. No. 2015/0080924. The disclosures of eachof the foregoing patents, publications, and applications areincorporated by reference herein. In addition, or in the alternative, atleast part of instrument (10) may be constructed and operable inaccordance with at least some of the teachings of U.S. Pub. No.2017/0105755, entitled “Surgical Instrument with Dual Mode End Effectorand Compound Lever with Detents,” published Apr. 20, 2017, thedisclosure of which is incorporated by reference herein; and/or U.S.Pat. App. No. 62/363,411, entitled “Surgical Instrument with Dual ModeEnd Effector,” filed Jul. 18, 2016, the disclosure of which isincorporated by reference herein.

As described in greater detail below, instrument (10) is operable to cuttissue and seal or weld tissue (e.g., a blood vessel, etc.)substantially simultaneously. It should also be understood thatinstrument (10) may have various structural and functional similaritieswith the HARMONIC ACE® Ultrasonic Shears, the HARMONIC WAVE® UltrasonicShears, the HARMONIC FOCUS® Ultrasonic Shears, and/or the HARMONICSYNERGY® Ultrasonic Blades. Furthermore, instrument (10) may havevarious structural and functional similarities with the devices taughtin any of the other references that are cited and incorporated byreference herein.

Instrument (10) in the present example includes a first modular assembly(100), a second modular assembly (200), and a coupling member (300). Aswill be described in greater detail below, coupling member (300) mayselectively attach first modular assembly (100) with second modularassembly (200) in order to form instrument (10) with an end effector(12). As best seen in FIGS. 1A-1B, end effector (12) comprises anultrasonic blade (150) and a clamp pad (222) of a clamp pad assembly(220).

Additionally, as will be described in greater detail below, selectedportions of second modular assembly (200) may actuate relative to firstmodular assembly (100), when properly attached with each other, in orderto actuate end effector (12) from an open configuration (FIGS. 1A and16A), to a closed configuration (FIGS. 1B and 16B). The ability toselectively attach and detach second modular assembly (200) with firstmodular assembly (100) may provide additional benefits of reusability ofeither modular assembly (100, 200). For instance, different kinds offirst modular assemblies (100) may be used with second modular assembly(200) to provide different kinds of surgical instruments. Similarly,different kinds of second modular assemblies (200) may be used withfirst modular assembly (100) to provide different kinds of surgicalinstruments. Additionally, moving components of second modular assembly(200) may be housed within static components of second modular assembly(200), which may provide additional advantages, some of which aredescribed below while others will be apparent to one having ordinaryskill in the art in view of the teachings herein.

First modular assembly (100) includes a handle assembly (110), a shaftassembly (130) extending distally from handle assembly (110), and anultrasonic blade (150) extending distally from shaft assembly (130).Handle assembly (110) includes a body (112), a finger grip ring (124), apair of buttons (126) distal to finger grip ring (124), and anultrasonic transducer assembly (30) housed within body (112).

Shaft assembly (130) includes a proximal outer sheath (132) extendingdistally from body (112), a tube (138) extending distally from proximalouter sheath (132), and a waveguide (140) extending within and throughboth proximal outer sheath (132) and tube (138). Proximal outer sheath(132) includes a pair of protrusions (136). Additionally, proximal outersheath (132) defines a pair of recesses (134). As will be described ingreater detail below, recesses (134) are dimensioned to mate with aportion of distal outer sheath (230) while protrusions (136) areconfigured to pivotally couple proximal outer sheath (132) with couplingmember (300). Both recesses (134) and protrusions (136) may help couplefirst modular assembly (100) with coupling member (300).

Proximal outer sheath (132) may be fixed relative to body (112), whiletube (138) may be fixed relative to proximal outer sheath (132). As willbe described in greater detail below, waveguide (140) may attach totransducer assembly (30) and be supported by portions proximal outersheath (132) and tube (138). Ultrasonic blade (150) may be unitarilyconnected to waveguide (140), and also extend distally from waveguide(140). As will be described in greater detail below, waveguide (140) isoperable to connect to ultrasonic transducer assembly (30) in order toprovide acoustic communication between ultrasonic blade (150) andtransducer assembly (30).

Referring to FIG. 4, ultrasonic transducer assembly (30) is housedwithin body (112) of handle assembly (110). As seen in FIGS. 1A-1B,transducer assembly (30) is coupled with a generator (5) via a plug(11). Transducer assembly (30) receives electrical power from generator(5) and converts that power into ultrasonic vibrations throughpiezoelectric principles. Generator (5) may include a power source andcontrol module that is configured to provide a power profile totransducer assembly (30) that is particularly suited for the generationof ultrasonic vibrations through transducer assembly (30). Generator (5)may also be configured to provide a power profile that enables endeffector (12) to apply RF electrosurgical energy to tissue.

By way of example only, generator (5) may comprise a GEN 300 sold byEthicon Endo-Surgery, Inc. of Cincinnati, Ohio. In addition or in thealternative, generator (not shown) may be constructed in accordance withat least some of the teachings of U.S. Pat. No. 8,986,302, entitled“Surgical Generator for Ultrasonic and Electrosurgical Devices,” issuedMar. 24, 2015, the disclosure of which is incorporated by referenceherein. It should also be understood that at least some of thefunctionality of generator (5) may be integrated into handle assembly(110), and that handle assembly (110) may even include a battery orother on-board power source such that plug (11) is omitted. Still othersuitable forms that generator (5) may take, as well as various featuresand operabilities that generator (5) may provide, will be apparent tothose of ordinary skill in the art in view of the teachings herein.

Ultrasonic vibrations that are generated by transducer assembly (30) arecommunicated along acoustic waveguide (140) when properly coupled.Waveguide (140) is mechanically and acoustically coupled with transducerassembly (30). Waveguide (140) extends through shaft assembly (130) toreach ultrasonic blade (150). Waveguide (140) may be secured to proximalouter sheath (132) and/or body (112) via a pin (135) extending throughwaveguide (140) and proximal outer sheath (132). Pin (135) may helpensure waveguide (140) remains longitudinally and rotationally fixedrelative to the rest of shaft assembly (130) when waveguide (140) is ina deactivated state (i.e. not vibrating ultrasonically).

Additionally, waveguide (140) may be supported by tube (138) via seals(142) located between an interior of tube (138) and an exterior ofwaveguide (140). Seals (142) may also prevent unwanted matter and fluidfrom entering portions of tube (138) housing waveguide (140). Pin (135)and seals (142) are located at positions along the length of waveguide(140) corresponding to nodes associated with resonant ultrasonicvibrations communicated through waveguide (140). Therefore, contactbetween waveguide (140) and pin (135), as well as contact betweenwaveguide (140) and seals (142) may not affect ultrasonic vibrationscommunicated through waveguide (154).

When ultrasonic blade (150) is in an activated state (i.e., vibratingultrasonically), ultrasonic blade (150) is operable to effectively cutthrough and seal tissue, particularly when the tissue is being clampedbetween clamp pad (222) and ultrasonic blade (150). It should beunderstood that waveguide (140) may be configured to amplify mechanicalvibrations transmitted through waveguide (140). Furthermore, waveguide(140) may include features operable to control the gain of thelongitudinal vibrations along waveguide (140) and/or features to tunewaveguide (140) to the resonant frequency of the system.

In the present example, the distal end of ultrasonic blade (150) islocated at a position corresponding to an anti-node associated withresonant ultrasonic vibrations communicated through waveguide (140), inorder to tune the acoustic assembly to a preferred resonant frequencyf_(o) when the acoustic assembly is not loaded by tissue. Whentransducer assembly (30) is energized, the distal end of ultrasonicblade (150) is configured to move longitudinally in the range of, forexample, approximately 10 to 500 microns peak-to-peak, and in someinstances in the range of about 20 to about 200 microns at apredetermined vibratory frequency f_(o) of, for example, 55.5 kHz. Whentransducer assembly (30) of the present example is activated, thesemechanical oscillations are transmitted through the waveguide to (140)reach ultrasonic blade (150), thereby providing oscillation ofultrasonic blade (150) at the resonant ultrasonic frequency. Thus, whentissue is secured between ultrasonic blade (150) and clamp pad (222),the ultrasonic oscillation of ultrasonic blade (150) may simultaneouslysever the tissue and denature the proteins in adjacent tissue cells,thereby providing a coagulative effect with relatively little thermalspread.

In some versions, an electrical current may also be provided throughultrasonic blade (150) and/or clamp pad (222) to also seal the tissue.It should therefore be understood that instrument (10) may also beconfigured to provide radiofrequency (RF) energy to a surgical site viaend effector (12). By way of example only, an operator may rely mainlyon the use of ultrasonic energy from blade (150) to sever tissue that iscaptured between ultrasonic blade (150) and clamp pad (222). Theoperator may further rely on the use of RF energy from end effector (12)to seal the severed tissue. Of course, it will be understood that theultrasonic energy from blade (150) may seal tissue to some degree, suchthat the RF energy from end effector (12) may supplement the sealingthat would already be provided from the ultrasonic energy. It will alsobe understood that there may be instances where the operator may wish tosimply use end effector (12) to only apply RF energy to tissue, withoutalso applying ultrasonic energy to tissue. As will be appreciated fromthe description herein, some versions of instrument (10) are capable ofproviding all of the above noted kinds of functionality. Various ways inwhich instrument (10) may be configured and operable to provide bothultrasonic and RF electrosurgical modes of operation are described invarious references cited herein; while other ways in which instrument(10) may be configured and operable to provide both ultrasonic and RFelectrosurgical modes of operation will be apparent to those of ordinaryskill in the art in view of the teachings herein.

An operator may activate buttons (126) to selectively activatetransducer assembly (30) to thereby activate ultrasonic blade (150). Inthe present example, two buttons (126) are provided. In some versions,one button (126) is provided for activating ultrasonic blade (150) at afirst power profile (e.g., a first frequency and/or first amplitude) andanother button (126) is provided for activating ultrasonic blade (150)at a second power profile (e.g., a second frequency and/or secondamplitude). In some other versions, one button (126) is provided foractivating ultrasonic blade (150) with ultrasonic energy, and the otherbutton (126) is provided for activating end effector (12) with RFenergy. In some other versions, one button (126) is operable to activateultrasonic blade (150) with ultrasonic energy while simultaneouslyactivating end effector (12) with RF energy; while the other button(126) is only operable to activate ultrasonic blade (150) withultrasonic energy. In some other versions, at least one button (126) isoperable to initially activate ultrasonic blade (150) with ultrasonicenergy, then based on one or more other conditions (e.g., time, measuredimpedance, etc.) while button (126) remains activated, eventuallyactivating end effector (12) with RF energy while still activatingultrasonic blade (150) with ultrasonic energy. In some other versions,at least one button (126) is operable to initially activate ultrasonicblade (150) with ultrasonic energy, then based on one or more otherconditions (e.g., time, measured impedance, etc.) while button (126)remains activated, eventually activating end effector (12) with RFenergy while ceasing activation of ultrasonic blade (150) withultrasonic energy. In some other versions, at least one button (126) isoperable to initially activate end effector (12) with RF energy, thenbased on one or more other conditions (e.g., time, measured impedance,etc.) while button (126) remains activated, eventually activatingultrasonic blade (150) with ultrasonic energy while ceasing activationof end effector (12) with RF energy.

It should be understood that any other suitable number of buttons and/orotherwise selectable power levels and/or power modalities may beprovided. For instance, a foot pedal may be provided to selectivelyactivate transducer assembly (30).

Buttons (126) of the present example are positioned such that anoperator may readily fully operate instrument (10) with a single hand.For instance, when first and second modular assemblies (100, 200) arecoupled, the operator may position their thumb in thumb grip ring (214),position their ring finger in finger grip ring (124), position theirmiddle finger about body (112), and manipulate buttons (126) using theirindex finger. Of course, any other suitable techniques may be used togrip and operate instrument (10); and buttons (126) may be located atany other suitable positions.

As mentioned above, and as will be described below, coupling member(300) is configured to selectively couple first modular assembly (100)with second modular assembly (200). As best seen in FIG. 7, couplingmember (300) comprises a body (302), a pair of resilient arms (304)extending from body (302), and a pair of grips (305) extending from body(302). Resilient arms (304) each define a respective pivot bore (306)and locking assembly (308). Resilient arms (304) are spaced apart fromeach other in order to receive proximal outer sheath (132) and tosnap-fit pivot bores (306) with respective protrusions (136). Therefore,as shown between FIGS. 13B-13C and 14B-14C, coupling member (300) isconfigured to pivotally connect with proximal outer sheath (132) viapivot bores (306) and protrusions (136). While in the current example,coupling member (300) and proximal outer sheath (132) are pivotallycoupled via snap-fitting, any other type of suitable connection may beused as would be apparent to one having ordinary skill in the art inview of the teachings herein. For example, protrusions (136) may beextendable relative to proximal outer sheath (132) in order to pivotallycouple with pivot bore (306) of coupling member (300). Grips (305) maybe positioned on body (302) such that an operator may easily rotatecoupling member (300) relative to outer sheath (132) via grips (305).

Each locking assembly (308) includes an interior contact wall (310)facing toward each other and a coupling recess (312). As will bedescribed in greater detail below, locking assembly (308) is configuredto rotate about pivot bore (306) and protrusions (136) in order toselectively couple with portions of second modular assembly (200).

While coupling member (300) in the current example is used to connectfirst modular assembly (100) with second modular assembly (200), itshould be understood that coupling member (300) may be incorporated intoany suitable type of modular assembly that would be apparent to onehaving ordinary skill in the art in view of the teachings herein. Forexample, coupling assembly (300) may be modified to couple differentmodular clamp arm assemblies with first modular assembly (100) where thedifferent modular clamp arm assemblies include clamp arm assemblies suchas those taught in U.S. Pub. No. 2017/0105788, entitled “SurgicalInstrument with Dual Mode End Effector and Modular Clamp Arm Assembly,”published Apr. 20, 2017, the disclosure of which is incorporated byreference herein. Thus, one modular clamp arm assembly that may becoupled with first modular assembly (100) may provide pivotal motion ofa clamp arm at one side of ultrasonic blade (150) while the othermodular clamp arm assembly that may be coupled with first modularassembly (100) may provide pivotal motion of a clamp arm at the otherside of ultrasonic blade (150). Other suitable kinds of clamp armassemblies that may be used to provide different kinds of second modularassemblies (200) will be apparent to those of ordinary skill in the artin view of the teachings herein.

Second modular assembly (200) includes a clamp arm assembly (210), aclamp pad assembly (220), and a distal outer sheath (230). As will bedescribed in greater detail below, distal outer sheath (230) isconfigured to couple with both coupling member (300) and proximal outersheath (132) in order to selectively couple first modular assembly (100)with second modular assembly (200). It other words, when properlycoupled, proximal outer sheath (132) and distal outer sheath (230) maybe fixed relative to one another. As will also be described in greaterdetail below, clamp arm assembly (210) and clamp pad assembly (220) areboth pivotally coupled with distal outer sheath (230). Additionally,clamp arm assembly (210) and clamp pad assembly (220) are dimensioned tomesh with each other such that rotation of one assembly (210, 220)relative to distal outer sheath (230) causes rotation of the otherassembly (210, 220) relative to distal outer sheath (230). In otherwords, clamp arm assembly (210) and clamp pad assembly (220) are capableof rotating each other relative to distal outer sheath (230).

Distal outer sheath (230) includes a U-shaped body (232) extending froma distal face (235) and terminating in a pair of proximally presentedprojections (234). Proximally presented projections (234) each include alateral protrusion (238) extending away from U-shaped body (232).U-shaped body (232) defines a longitudinal pathway (236) and a pluralityof bores (240). U-shaped body (232) and longitudinal pathway (236) aredimensioned to receive tube (138) and to rotationally house a portion ofclamp arm assembly (210) and clamp pad assembly (220). In particular, asbest shown between FIGS. 13A-13B, U-shaped body (232) may be insertedover ultrasonic blade (150) and tube (138) such that tube (138) willrest under clamp arm assembly (210) and clamp pad assembly (220). Tube(138) may protect waveguide (140) such that clamp arm assembly (210) andclamp pad assembly (220) do not contact adjacent portions of waveguide(140).

As shown between FIGS. 13A-13B and between FIGS. 14A-14B, proximallypresented projections (234) are configured to be inserted into recesses(134) defined by proximal outer sheath (132). When proximally presentedprojections (234) are inserted into recesses (134), distal outer sheath(230) may not rotate relative to proximal outer sheath (132) about alongitudinal axis defined by tube (138). Therefore, proximally presentedprojections (234) may mate with recesses (134) in order to rotationallyfix distal outer sheath (230) relative to proximal outer sheath (132).

As shown between FIGS. 13B-13C, between FIGS. 14B-14D, and between FIGS.15A-15C, once distal outer sheath (230) is rotationally fixed relativeto proximal outer sheath (132), an operator may rotate coupling member(300) such that locking assembly (308) snap-fits with lateralprotrusions (238). In particular, an operator may rotate coupling member(300) about protrusion (136) such that lateral protrusions (238) camagainst contact walls (310) of resilient arms (304). As a result, asbest seen in FIG. 15B, contact between contact walls (310) and lateralprotrusions (238) flex resilient arms (304) outwardly away fromproximally presented projections (234). An operator may further rotatecoupling member (300) about protrusions (136) such that lateralprotrusions (238) no longer abut against contact wall (310), as shown inFIGS. 13C, 14C, and 15C. The resilient nature of resilient arms (304)allows resilient arms (304) to return to a relaxed position such thatlateral protrusions (238) rest within coupling recess (312) of lockingassembly (308). With locking assembly (308) of coupling member (300)fully attached, and shown in FIGS. 13C, 14D, and 15C, distal outersheath (230) is longitudinally fixed relative to proximal outer sheath(132), thereby coupling first modular assembly (100) with second modularassembly (200).

If an operator wishes to decouple first modular assembly (100) withsecond modular assembly (200), an operator may grasp grips (305) torotate coupling member (300) in the opposite direction about protrusions(136) in order to flex resilient arms (304) to pop out lateralprotrusions (238) from coupling recess (312).

As mentioned above, clamp arm assembly (210) and clamp pad assembly(220) are both pivotally coupled with distal outer sheath (230) suchthat rotation of one assembly (210, 220) relative to distal outer sheath(230) causes rotation of the other assembly (210, 220) relative todistal outer sheath (230).

Clamp arm assembly (210) includes an elongated arm (212), a thumb gripring (214), a camming protrusion (216), and a pivot coupling (218).Thumb grip ring (214) and elongated arm (212) together provide a scissorgrip type configuration in combination with body (112) and finger gripring (124). Pivot coupling (218) pivotally couples clamp arm assembly(210) with distal outer sheath (230) via pins (202). As will bedescribed in greater detail below, camming protrusion (216) interactswith clamp pad assembly (220) in order to rotate clamp pad assembly(220) in response to rotation of clamp arm assembly (210).

Clamp pad assembly (220) includes a clamp pad (222) facing ultrasonicblade (150), a pair of tissue stops (223) located adjacent to ultrasonicblade (150) and proximal to clamp pad (222), an arm (224) defining botha camming recess (226) and a spring recess (221), a pivot coupling(228), and a leaf spring (225) housed within spring recess (221). Insome versions, clamp pad assembly (220) further includes one or moreelectrodes that is/are operable to apply RF electrosurgical energy totissue. Various references herein provide examples of how a clamp padassembly may incorporate one or more electrodes that is/are operable toapply RF electrosurgical energy to tissue, while other examples of howclamp pad assembly (220) may incorporate one or more electrodes thatis/are operable to apply RF electrosurgical energy to tissue will beapparent to those of ordinary skill in the art in view of the teachingsherein.

In the current example, tissue stops (223) longitudinally align withdistal face (235) when end effector (12) is in the closed position.Tissue stops (223) and distal face (235) may cooperate to consistentlyand simply prevent tissue from inadvertently reaching a proximalposition within end effector (12) where ultrasonic energy from blade(150) may not adequately sever or seal the tissue. In providing suchprevention, tissue stop (223) may eliminate the need for an operator tovisualize proximal region of end effector (12) in order to determinewhether the tissue has reached an undesirably proximal position withinend effector (12).

Camming protrusion (216) is dimensioned to rotate within camming recess(226) while also contacting camming recess (226). Camming protrusion(216) and camming recess (226) are positioned within distal outer sheath(230) such that both are located between pivot couplings (218, 228)while clamp arm assembly (210) and clamp pad assembly (220) arepivotally coupled to distal outer sheath (230). Therefore, as shownbetween FIGS. 1A-1B and 16A-16B, when an operator rotates elongated arm(212) about pivot coupling (218) toward distal outer sheath (230),camming protrusion (216) rotates away from distal outer sheath (230)about pivot coupling (218). Because camming protrusion (216) is housedwithin camming recess (226), upward movement of camming protrusion (216)about pivot coupling (218) causes upward movement of camming recess(226) about pivot coupling (228). Upward movement of camming recess(226) about pivot coupling (228) rotates arm (224) such that clamp pad(222) rotates toward ultrasonic blade (150). Therefore, closure ofelongated arm (212) of clamp arm assembly (210) toward handle assembly(110) leads to closure of clamp pad (222) toward ultrasonic blade (150).It should therefore be understood that when first modular assembly (100)and second modular assembly (200) are connected, an operator may squeezethumb grip ring (214) toward body (112) to thereby clamp tissue betweenclamp pad assembly (220) and ultrasonic blade (150) to compress tissueagainst ultrasonic blade (150). When ultrasonic blade (150) is activatedduring such compression, clamp pad assembly (220) and ultrasonic blade(150) cooperate to transect and/or seal the compressed tissue.

As mentioned above, leaf spring (225) is housed within spring recess(221). As best seen in FIGS.16A-16B, leaf spring (225) is dimensionedsuch that a portion of leaf spring (225) extends out of spring recess(221) to make contact against tube (138) in order to provide electricalcontinuity between the one or more RF electrodes of end effector (12)and the source of electrical power. It should be understood that leafspring (225) maintains this electrical continuity throughout the rangeof motion of clamp pad assembly (220). It should also be understood thatany other suitable kinds of features may be used to provide electricalcontinuity between the one or more RF electrodes of end effector (12)and the source of electrical power.

In some versions, one or more resilient members are used to bias clamppad assembly (220) toward the open position shown in FIGS. 1A and 16A.Of course, any other suitable kind of resilient member may be used aswould be apparent to one having ordinary skill in the art in view of theteachings herein, such as a torsion spring. Alternatively, clamp padassembly (220) need not necessarily be biased toward the open position.

Pivot couplings (218, 228) of clamp arm assembly (210) and clamp padassembly (220) being located within longitudinal pathway (236) of distalouter sheath (230) may provide certain desirable advantages as comparedto clamp arm assembly (210) and clamp pad assembly (220) pivotallycoupling with an exterior of distal outer sheath (230). For instance,there may be a reduced chance of inadvertently pinching tissue due torotation of clamp arm assembly (210) and clamp pad assembly (220) withpivot couplings (218, 228) being housed within U-shaped body (232). Inother words, U-shaped body (232) may protect tissue from beinginadvertently pinched by rotation of clamp arm assembly (210) and clamppad assembly (220) relative to distal outer sheath (230). Additionally,the width of second modular assembly (200) may be reduced due to pivotcouplings (218, 228) being housed within longitudinal pathway (236) ofdistal outer sheath (230). It may also be easier to fabricate desiredcomponents due to the simplified shapes of clamp arm assembly (210) andclamp pad assembly (220). A reduction of tolerance stack may also be anadvantage to storing pivot couplings (218, 228) within the interior ofdistal outer sheath (230).

The foregoing components and operabilities of instrument (10) are merelyillustrative. Instrument (10) may be configured in numerous other waysas will be apparent to those of ordinary skill in the art in view of theteachings herein. By way of example only, at least part of instrument(10) may be constructed and/or operable in accordance with at least someof the teachings of any of the following, the disclosures of which areall incorporated by reference herein: U.S. Pat. No. 5,322,055; U.S. Pat.No. 5,873,873; U.S. Pat. No. 5,980,510; U.S. Pat. No. 6,325,811; U.S.Pat. No. 6,783,524; U.S. Pub. No. 2006/0079874; U.S. Pub. No.2007/0191713; U.S. Pub. No. 2007/0282333; U.S. Pub. No. 2008/0200940;U.S. Pat. No. 9,023,071; U.S. Pat. No. 8,461,744; U.S. Pat. No.9,381,058; U.S. Pub. No. 2012/0116265; U.S. Pat. No. 9,393,037; U.S.Pat. No. 9,095,367; and/or U.S. Pub. No. 2015/0080925, entitled“Alignment Features for Ultrasonic Surgical Instrument,” published Mar.19, 2015, the disclosure of which is incorporated by reference herein.

II. SECOND EXEMPLARY ULTRASONIC SURGICAL INSTRUMENT FOR OPEN SURGICALPROCEDURES

FIGS. 17-18 show a second exemplary ultrasonic surgical instrument(301). Except as otherwise described below, instrument (301) of thisexample may be constructed and operable just like instrument (10)described above. Certain details of instrument (301) will therefore beomitted from the following description, it being understood that suchdetails are already provided above in the description of instrument(10).

Instrument (301) of the present example comprises a handle assembly(311), a clamp arm actuator (320), a shaft assembly (330), and a clamparm assembly (400). Handle assembly (311) of this example is configuredand operable just like handle assembly (110) described above, such thatdetails of handle assembly (311) will not be reiterated here.

Clamp arm actuator (320) is pivotably coupled with shaft assembly (330).In the present example, clamp arm actuator (320) is not removable fromshaft assembly (330). Clamp arm actuator (320) of the present examplecomprises a shaft (322). A thumb ring (324) is positioned at theproximal end of shaft (322). As best seen in FIGS. 18-19, pair ofprojections (326) extend distally from shaft (322). Projections (326)are laterally spaced apart from each other and extend parallel to eachother. As best seen in FIG. 19, the distal end of each projection (326)includes a camming protrusion (328). Camming protrusions (328) areconfigured to cooperate with clamp arm assembly (400), in a mannersimilar to camming protrusions (216), as will be described below. Asalso best seen in FIG. 19, projections (326) also define a pair of pinopenings (327), which are configured to receive pin (338). Pin (338)provides a pivotable coupling between clamp arm actuator (320) and shaftassembly (330).

Shaft assembly (330) extends distally from handle assembly (311) and issubstantially identical to shaft assembly (130) described above exceptfor the differences described below. An ultrasonic blade (350), which isidentical to ultrasonic blade (150) described above, is positioned atthe distal end of shaft assembly (130). As best seen in FIG. 20, shaftassembly (330) defines an opening (332) that is configured to receivepin (338) to thereby provide a pivotable coupling between clamp armactuator (320) and shaft assembly (330). As also shown in FIG. 20, shaftassembly (330) includes a ramped latch protrusion (334), which isconfigured to engage clamp arm assembly (400) as will be described ingreater detail below.

As shown in FIGS. 21-22, clamp arm assembly (400) of the present examplecomprises a pair of shrouds (402, 404) partially encompassing a clamparm body (430), which is pivotally coupled with a stationary body (410).Each shroud includes a distally presented tissue stop edge (408).Stationary body (410) also includes a pair of distally presented tissuestop edges (418). Edges (408, 418) are configured to cooperate toconsistently and restrict proximal positioning of tissue like tissuestops (223) and distal face (235) described above. Shroud (404) of thepresent example also includes a distally projecting shield member (406).

Stationary body (410) of the present example further includes a pinopening (411) and a proximally projecting latch member (412). Latchmember (412) defines a latch opening (414) and a ramp (416). Latchmember (412) is configured to cooperate with latch protrusion (334) ofshaft assembly (330) to selectively secure clamp arm assembly (400) toshaft assembly (330). In particular, when clamp arm assembly (400) isinitially provided separately from shaft assembly (330), an operator mayalign clamp arm assembly (400) with shaft assembly (330) along a commonaxis, and then insert blade (350) and the remaining distal portion ofshaft assembly (330) into clamp arm assembly (400). Ramp (416) willeventually engage latch protrusion (334), which will provide a cammingaction that causes latch member (412) to deflect away from thelongitudinal axis. As the operator continues to insert shaft assembly(330) through clamp arm assembly (400), latch protrusion (334)eventually reaches latch opening (414), at which point latch member(412) resiliently returns to a straight, non-deflected state. At thisstage, latch protrusion (334) is disposed in latch opening (414) andthereby secures clamp arm assembly (400) to shaft assembly (330). Whenthe operator wishes to remove clamp arm assembly (400) from shaftassembly (330), the operator may simply engage ramp (416) and therebyurge latch member (412) to a deflected state where latch member (412)can clear latch protrusion (334); then pull clamp arm assembly (400)away from shaft assembly (330). Other suitable structures and techniquesthat may be used to secure clamp arm assembly (400) to shaft assembly(330), and to remove clamp arm assembly (400) from shaft assembly (330),will be apparent to those of ordinary skill in the art in view of theteachings herein.

Clamp arm body (430) of the present example comprises a clamp pad (432)and a pair of proximal projections (434). Clamp pad (432) is positionedand configured to compress tissue against ultrasonic blade (350) whenclamp arm assembly (400) is secured to shaft assembly (330). Shieldmember (406) of shroud (404) is configured to extend over the exteriorof the distal end of clamp arm body (430), without covering clamp pad(432). Shield member (406) thus enables clamp pad (432) to contacttissue directly. Projections (438) each comprise a respective proximallypresented recess (436) and a pair of pin openings (438). A pin (440) ispositioned in pin openings (411, 438) to thereby pivotally couple clamparm body (430) with stationary body (410). Shrouds (402, 404) arefixedly secured to clamp arm body (430) such that shrouds (402, 404)pivot with clamp arm body (430) relative to stationary body (410).

As shown in FIG. 23, recesses (436) have a generally U-shapedconfiguration. Recesses (436) are configured to receive cammingprotrusions (328) of clamp arm actuator (320). In other words, whenshaft assembly (330) is inserted into clamp arm assembly (400) asdescribed above, camming protrusions (328) will enter recesses (436)when latch member (412) reaches the point at which latch member (412)secures clamp arm assembly (400) to shaft assembly (330). When theoperator removes clamp arm assembly (400) from shaft assembly (330),camming protrusions (328) may freely exit recesses (436), as clamp armactuator (320) remains secured to shaft assembly (330). As best seen inFIG. 17, shrouds (402, 404) are configured to cover the interfacesbetween recesses (436) and camming protrusions (328). It should beunderstood that the relationship between recesses (436) and cammingprotrusions (328) is substantially identical to the relationship betweencamming protrusion (216) and camming recess (226) described above. Thus,recesses (436) and camming protrusions (328) provide a pivoting couplingbetween clamp arm body (430) and clamp arm actuator (320).

As noted above, clamp arm actuator (320) is pivotally coupled with shaftassembly (330) via pin (338); and clamp arm body (430) is pivotallycoupled with stationary body (410) via pin (440); while stationary body(410) is fixedly secured to shaft assembly (330). The pivoting interfacebetween recesses (436) and camming protrusions (328) is longitudinallypositioned between the longitudinal positions of pins (338, 440). Itshould therefore be understood that clamp arm actuator (320) and clamparm body (430) cooperate to provide a compound lever assembly. When anoperator pivots thumb ring (324) toward handle assembly (311), thecompound lever action provides corresponding pivotal movement of clamppad (432) toward ultrasonic blade (350).

In the present example, a resilient beam (313) is secured to clamp armactuator (320) and slidably bears against shaft assembly (330), suchthat resilient beam (313) resiliently urges clamp arm actuator (320)away from handle assembly (311). Thus, when an operator relaxes theirgrip on thumb ring (324), resilient beam (313) will urge thumb ring(324) away from handle assembly (311), thereby urging clamp pad (432)away from ultrasonic blade (350). Of course, any other suitablecomponents and arrangements may be used to provide a resilient bias toclamp arm actuator (320). Alternatively, such resilient bias may simplybe omitted.

III. EXEMPLARY SURGICAL INSTRUMENT WITH SPOT COAGULATION MODE

In some instances, it may be beneficial for an ultrasonic surgicalinstrument to provide the operator with a custom mode of operation,specifically a spot coagulation mode. Improving the ability ofultrasonic surgical instruments, such as surgical instrument (10, 301)discussed above, to form a predetermined gap at end effector (12) may bedesirable when providing ultrasonic and/or RF energy to a patient'stissue, such as performing a spot coagulation on a patient's tissue.Exemplary instruments and features directed to forming a predeterminedgap at end effector (12) are described in U.S. Pat. App. No. [ATTORNEYDOCKET NO. END8130USNP2.0652948], entitled “Surgical Instrument withSelectively Actuated Gap-Setting Features for End Effector,” filed oneven date herewith, the disclosure of which is incorporated by referenceherein. Various suitable ways in which the teachings herein may becombined with the teachings of U.S. Pat. App. No. [ATTORNEY DOCKET NO.END8130USNP2.0652948] will be apparent to those of ordinary skill in theart in view of the teachings herein.

Referring now to the figures, FIG. 24 shows a third exemplary surgicalinstrument (6900) operable to transition between a cut/seal mode to aspot coagulation mode. As seen in FIG. 25, an end effector (6940) ofsurgical instrument (6900) comprises an ultrasonic blade (6942) and aclamp arm (6944). Clamp arm (6944) includes a top pad (6945) and abottom pad (6947), where top pad (6945) includes a first pole (6946) andbottom pad includes a second pole (6948). First pole (6946) is a vesselsealing electrode, or a negative electrode more commonly referred to asa cathode. Ultrasonic blade (6492) is operatively connected to atransducer (not shown) in surgical instrument (6900). Second pole (6948)is a radio frequency (RF) electrode, or a positive electrode morecommonly referred to as an anode. As best seen in FIG. 28, top pad(6945) and bottom pad (6947) are spaced apart within clamp arm (6944) bya gap (6949). In some versions, an electrically insulating materialcould define gap (6949) or be located in place of gap (6949) where gap(6949) is otherwise a void space between top pad (6945) and bottom pad(6947). Ultrasonic blade (6942) includes a third pole (6943), as seen inFIG. 25. Third pole (6943), similar to second pole (6948), is a radiofrequency (RF) electrode, or a positive electrode more commonly referredto as an anode. In some versions, third pole (6943) is in the form of anelectrode surface or other surface that is applied to or otherwiseintegrated into the material forming ultrasonic blade (6942). In someother versions, the entirety of ultrasonic blade (6942) serves as thirdpole (6943).

Second pole (6948) of clamp arm (6944) is positioned to proximally facethird pole (6943) of ultrasonic blade (6942). Gap (6949) is configuredto separate first pole (6946) from second pole (6948) at a predeterminedtransverse distance. Another gap (6960) is formed between second pole(6948) and third pole (6943) of ultrasonic blade (6942).

In the present example, as seen in FIG. 24, handle body (6910) includesa first button (6912) and a second button (6914). First button (6912)transversely extends from handle body (6910) towards clamp arm actuator(6930) and is configured to activate the cut/seal mode of surgicalinstrument (6900). First button (6912) becomes actuated as clamp armactuator (6930) moves toward handle body (6910) and engages againstfirst button (6912), as seen in FIG. 26. In this instance, ultrasonicblade (6942) is configured to close against clamp arm (6944) to theclosed position, as shown in FIG. 27.

Second button (6914) is configured to activate the spot coagulation modeof surgical instrument (6900). With second button (6914) actuated by anoperator, spot coagulation mode is initiated and is configured tooperate an algorithm to activate poles (6946, 6948) of clamp arm (6944)and third pole (6943) of ultrasonic blade (6942). Spot coagulation modeis configured to maintain a predetermined gap (6960) at end effector(6940) with clamp arm actuator (6930) moved relative to handle body(6910) to at least a predetermined degree. In other words, spotcoagulation mode is configured to maintain predetermined gap (6960)irrespective of the relative position of clamp arm actuator (6930) tohandle body (6910) so long as the predetermined minimum degree ofmovement by clamp arm actuator (6930) towards handle body (6910) issatisfied. Therefore, with second button (6914) activated and firstbutton (6912) not engaged, spot coagulation mode is configured todeactivate with clamp arm actuator (6930) not moved relative to handlebody (6910) at least to the predetermined minimum degree.

Spot coagulation mode is further configured to remain active untilsecond button (6914) is actuated, or until clamp arm actuator (6930)engages first button (6912) with clamp arm actuator (6930) movedrelative to handle body (1910) to the closed configuration. Furthermore,spot coagulation mode is configured to deactivate with clamp armactuator (6930) substantially moved towards handle body (6910) butwithout engaging first button (6912). In this instance, the algorithm ofspot coagulation mode perceives end effector (6940) to be in the closedposition, due to the insignificant space positioned between ultrasonicblade (6942) and clamp arm (6944), and is thereby configured todeactivate the spot coagulation mode.

IV. COAGULATION ALGORITHM

As shown in FIG. 30, a method (9400) is provided to enable a continuousactivation for spot coagulation utilizing simultaneous activation ofadvanced bipolar (RF) and ultrasonic energies. Spot coagulation presentsa challenge in that the device must continuously activate the underlyingenergy both in air and in tissue and in some environments, advancedbipolar (RF) energy may short circuit when activated in air due to thehigh impedance detected.

In this dual energy method (9400), the advanced bipolar (RF) modalitycreates a strong sealing of the tissue, while the ultrasonic activationreduces the amount of sticking by balancing the thermal effect on boththe blade and the clamp pad/arm, such as ultrasonic blade (150) andclamp pad (222) of instrument (10).

In general, method (9400) is directed to lowering one or both of theultrasonic and RF energy between tissue contact to a low energy level,without completely halting the energy as many energy generating elementscannot support quickly stopping and starting the generated energy. Upondetection of a tissue contact, the low energy level is increased to aworking energy level to perform the spot coagulation. Upon release ofthe tissue contact, the working energy level is decreased to the lowenergy level and the cycle repeats. Rather than completely halting theRF and/or ultrasonic energy between tissue contacts, the low energylevel is provided between tissue contacts to prevent a transition fromno energy to a working energy level, which may produce a significantamount of blood spatter.

Method (9400) begins with a step (9402), whereby a surgeon activates aspot coagulation device. Thereafter, step (9402) moves to a step (9404).In step (9404), the device outputs a low RF pulse to interrogate tissueas well as a sub-therapeutic ultrasonic activation to maintain lock. Insome versions of method (9400), sub-therapeutic is associated with a lowenough amplitude to prevent a shut-down of the instrument being used toprovide the energy and/or lower than a standard amplitude for the energyin the given environment. By providing a sub-therapeutic level of energybetween tissue contacts, a transition from no energy to the workingenergy level is prevented, as a transition from no energy to the workingenergy may produce a significant amount of blood spatter. In someversions of method (9400), maintaining lock is associated withmaintaining a particular resonant frequency in an acoustic drivetrain toprevent a generator of the energy from shutting down. The locking isdirected to staying a close as possible to a zero phase angle between acurrent and a voltage of the energy in order to minimize impedance.

Thereafter, step (9404) moves to a step (9406). In step (9406), theimpedance of the RF pulse is checked or collected. If the impedance ofthe RF pulse is above a particular set threshold, step (9406) moves to astep (9408). If the impedance of the RF pulse is below the particularthreshold, step (9406) moves to a step (9410). In the illustratedexample, the threshold is set to 4000 ohms. This threshold is selectedto indicate when the device's jaws are in air or one jaw is touchingtissue, while the other jaw is not. If the device's jaws are in air orone jaw is touching tissue, the impedance of the RF pulse will be abovethe threshold. If step (9406) determines that the RF pulse is above thethreshold, step (9406) moves to step (9408) and step (9408) returns tostep (9404) to complete a loop of impedance checking using a low RFpulse within method (9400).

If step (9406) determines that the measured impedance of the RF pulse isbelow the threshold, step (9406) proceeds to step (9410). Step (9410)recognizes that because the measured impedance is below the threshold,there is tissue contact between the device's jaws. Step (9410)thereafter proceeds to a step (9412), where both the RF energy and theultrasonic energy is changed to compensate for the tissue contactbetween the device's jaws. In some versions of step (9412), compoundload curve tables are activated for use in updating the RF energy. Inother versions of step (9412), ultrasonic energy is activated with anintermediate power level between a lower power level and a higher level,such as a power level “2” between a lower power level of “1” and ahigher power level of “5.” In other versions, both compound load curvesand intermediate power level are activated simultaneously to updatetheir reflective energies.

After the RF and/or ultrasonic energies are updated to compensate forthe tissue contact between the device's jaws, step (9412) returns tostep (9406) to continue checking the RF impedance in a loop of steps(9406, 9410, 9412). If the impedance changes, step (9406) will proceedto step (9408) and ultimately adjust the RF pulse in step (9404) toreflect the change in impedance.

A spot coagulation instrument similar to instrument (10) of FIG. 1A maybe provided and configured to perform one or more steps of method(9400). Some versions of the spot coagulation instrument may be providedwith a closure switch and a feedback feature. The feedback feature maybe configured to provide feedback to the user when the closure switch isdepressed and the impedance is above the threshold. Alternatively, thefeedback feature may be configured to provide feedback to the user whenthe closure switch is depressed and the impedance is below thethreshold. This feedback may be in the form of an audible feedback suchas an audible tone, a visual feedback such as a light, or a tactilefeedback such as a vibration of one or more portions of the spotcoagulation instrument.

V. EXEMPLARY COMBINATIONS

The following examples relate to various non-exhaustive ways in whichthe teachings herein may be combined or applied. It should be understoodthat the following examples are not intended to restrict the coverage ofany claims that may be presented at any time in this application or insubsequent filings of this application. No disclaimer is intended. Thefollowing examples are being provided for nothing more than merelyillustrative purposes. It is contemplated that the various teachingsherein may be arranged and applied in numerous other ways. It is alsocontemplated that some variations may omit certain features referred toin the below examples. Therefore, none of the aspects or featuresreferred to below should be deemed critical unless otherwise explicitlyindicated as such at a later date by the inventors or by a successor ininterest to the inventors. If any claims are presented in thisapplication or in subsequent filings related to this application thatinclude additional features beyond those referred to below, thoseadditional features shall not be presumed to have been added for anyreason relating to patentability.

Example 1

A surgical instrument, comprising: (a) an end effector, including: (i)an ultrasonic blade, (ii) a clamp arm configured to move relative to theultrasonic blade from an opened position toward a closed position,wherein the ultrasonic blade and the clamp arm are configured to receivetissue in the opened position, wherein the clamp arm is configured toclamp tissue against the ultrasonic blade in the closed position, (iii)a first electrode operably connected with the clamp arm, (iv) a secondelectrode associated with the ultrasonic blade, wherein the electrodesare operable to apply bipolar radiofrequency (RF) energy to tissuecaptured in the end effector; (b) a clamp arm actuator operativelyconnected to the clamp arm and configured to selectively direct theclamp arm respectively from the opened position toward the closedposition; (c) a first button operable to activate the ultrasonic bladeto thereby provide a cutting and sealing mode at the end effector; and(d) a second button operable to activate the electrodes to therebyprovide a spot coagulation mode at the end effector.

Example 2

The surgical instrument of Example 1, further comprising a shaftassembly projecting proximally from the end effector and including anacoustic waveguide operatively connected to the ultrasonic blade,wherein the acoustic waveguide is configured to connect to an ultrasonictransducer.

Example 3

The surgical instrument of Example 2, further comprising a bodyprojecting proximally from the shaft assembly.

Example 4

The surgical instrument of Example 3, wherein the first and secondbuttons are located on the body.

Example 5

The surgical instrument of Example 3, wherein the first button islocated on the body, wherein the first button transversely extends fromthe body toward the clamp arm actuator.

Example 6

The surgical instrument of any of Example 3 through Example 5, whereinthe first button is configured to be actuated as the clamp arm actuatormoves toward the body and engages against the first button.

Example 7

The surgical instrument of any of Example 3 through Example 6, whereinthe clamp arm actuator has a proximal end, wherein the body has aproximal end, wherein the proximal end of the actuator is movable towardthe proximal end of the body to thereby urge the clamp arm toward theclosed position, wherein the first button is located at the proximal endof the body, wherein the first button is configured to be actuated bythe proximal end of the clamp arm actuator.

Example 8

The surgical instrument of any of Example 1 through Example 7, whereinthe second button is located distally relative to the first button.

Example 9

The surgical instrument of any of Example 1 through Example 8, whereinthe clamp arm comprises a top pad and a bottom pad, wherein the bottompad is located between the top pad and the ultrasonic blade.

Example 10

The surgical instrument of Example 9, wherein the top pad and the bottompad are spaced apart within the clamp arm.

Example 11

The surgical instrument of any of Example 9 through Example 10, whereinthe first electrode is included with the top pad.

Example 12

The surgical instrument of any of Example 9 through Example 11, furthercomprising a third electrode included with the bottom pad, wherein thethird electrode has opposite polarity of the first electrode.

Example 13

The surgical instrument of Example 12, wherein the third electrode is aradio frequency (RF) electrode.

Example 14

The surgical instrument of any of Example 1 through Example 12, whereinthe ultrasonic blade defines the second electrode.

Example 15

The surgical instrument of any of Example 1 through Example 11, whereinthe clamp arm further comprises a third electrode positioned toproximally face the second electrode of the ultrasonic blade.

Example 16

The surgical instrument of any of Example 1 through Example 15, whereinthe second button is on the body extending towards the clamp armactuator.

Example 17

A surgical instrument, comprising: (a) an end effector, including: (i)an ultrasonic blade providing a first electrode, and (ii) a clamp armconfigured to move relative to the ultrasonic blade from an openedposition toward an intermediate position and a closed position, whereinthe ultrasonic blade and the clamp arm are configured to receive tissuein the opened position, wherein the clamp arm is configured to clamptissue against the ultrasonic blade in the closed position, wherein theclamp arm is offset from the ultrasonic blade to define a predeterminedgap in the intermediate position between the opened position and theclosed position, wherein the clamp arm includes a second electrode and athird electrode configured to be separately spaced to bias the clamp armand the ultrasonic blade to the intermediate position, wherein the firstand second electrodes have poles opposite of the third electrode,wherein the second electrode is positioned within the clamp arm actuatorproximal to the ultrasonic blade relative to the third electrode; (b) ashaft assembly projecting proximally from the end effector and includingan acoustic waveguide operatively connected to the ultrasonic blade,wherein the acoustic waveguide is configured to connect to an ultrasonictransducer; (c) a body projecting proximally from the shaft assembly;(d) a clamp arm actuator operatively connected to the clamp arm andconfigured to selectively move relative to the body from an openedconfiguration to a closed configuration to thereby direct the clamp armrespectively from the opened position toward the intermediate positionand the closed position; (e) a first button operable to activate thefirst, second and third electrodes; and (f) a second button configuredto deactivate the first, second and third electrodes when the clamp armactuator is in the closed configuration.

Example 18

A method of performing coagulation using a surgical instrument, themethod comprising: (a) delivering an ultrasonic energy to an endeffector at a first ultrasonic intensity; (b) delivering aradiofrequency (RF) energy to the end effector at a first RF intensity;(c) detecting a contact of the end effector with a tissue; and (d) inresponse to detecting the contact of the end effector with the tissue,changing one or both of the first ultrasonic intensity to a secondultrasonic intensity or the first RF intensity to a second RF intensity.

Example 19

The method of Example 18, further comprising: (a) detecting a release ofthe end effector from the tissue; and (b) upon detecting the release ofthe end effector from the tissue, changing one or both of the secondultrasonic intensity to the first ultrasonic intensity or the second RFintensity to the first RF intensity.

Example 20

The method of any of Example 18 through Example 19, wherein the act ofdetecting a contact of the end effector with a tissue comprisescomparing a threshold impedance value for an RF pulse with an observedimpedance value for the RF pulse, wherein the contact of the endeffector with the tissue exists when the observed impedance value forthe RF pulse is below the threshold impedance value for the RF pulse.

Example 21

The method of Example 20, wherein the threshold impedance vlaude is setto 4000 ohms.

VI. MISCELLANEOUS

While various examples herein describe two or more modular componentsbeing releasably coupled together, it should be understood that somevariations may eliminate such modularity and releasable couplings. Forinstance, some versions of instrument (10) may provide first modularassembly (100) and second modular assembly (200) as a single combinedunit that does not permit second modular assembly (200) to be removedform first modular assembly (100). In some such versions, couplingmember (300) would either me omitted (with some other feature being usedto provide permanent coupling between first modular assembly (100) andsecond modular assembly (200)); or coupling member (300) may be modifiedsuch that coupling member (300) may not be manipulated to decouplesecond modular assembly (200) from first modular assembly (100).Similarly, some versions of instrument (301) may prevent clamp armassembly (400) from being removed from shaft assembly (330). Forinstance, latch member (412) may be omitted and clamp arm assembly (400)may be permanently coupled with shaft assembly (330).

It should be understood that the various teachings herein may be readilycombined with the various teachings of U.S. Pub. No. 2017/0105754,entitled “Surgical Instrument with Dual Mode End Effector andSide-Loaded Clamp Arm Assembly,” published on Apr. 20, 2017, thedisclosure of which is incorporated by reference herein. Varioussuitable ways in which the teachings herein may be combined with theteachings of U.S. Pub. No. 2017/0105754 will be apparent to those ofordinary skill in the art.

It should be understood that the various teachings herein may be readilycombined with the various teachings of U.S. Pub. No. 2017/0105755,entitled “Surgical Instrument with Dual Mode End Effector and CompoundLever with Detents,” published Apr. 20, 2017, the disclosure of which isincorporated by reference herein. Various suitable ways in which theteachings herein may be combined with the teachings of U.S. Pub. No.2017/0105755 will be apparent to those of ordinary skill in the art.

It should be understood that the various teachings herein may be readilycombined with the various teachings of U.S. Pub. No. 2017/0105788,entitled “Surgical Instrument with Dual Mode End Effector and ModularClamp Arm Assembly,” published Apr. 20, 2017, the disclosure of which isincorporated by reference herein. Various suitable ways in which theteachings herein may be combined with the teachings of U.S. Pub. No.2017/0105788 will be apparent to those of ordinary skill in the art.

The various instruments described above may be used in a variety ofkinds of surgical procedures. By way of example only, the instrumentsdescribed above may be used to perform liver resection, colorectalsurgical procedures, gynecological surgical procedures, and/or variousother kinds of surgical procedures. Various other kinds of proceduresand ways in which the instruments described above may be used will beapparent to those of ordinary skill in the art in view of the teachingsherein.

It should be understood that any of the versions of instrumentsdescribed herein may include various other features in addition to or inlieu of those described above. By way of example only, any of theinstruments described herein may also include one or more of the variousfeatures disclosed in any of the various references that areincorporated by reference herein. It should also be understood that theteachings herein may be readily applied to any of the instrumentsdescribed in any of the other references cited herein, such that theteachings herein may be readily combined with the teachings of any ofthe references cited herein in numerous ways. Other types of instrumentsinto which the teachings herein may be incorporated will be apparent tothose of ordinary skill in the art.

In addition to the foregoing, the teachings herein may be readilycombined with the teachings of U.S. Pat. App. No. [ATTORNEY DOCKET NO.END8130USNP.0652942], entitled “Surgical Instrument with Removable ClampArm Assembly,” filed on even date herewith, the disclosure of which isincorporated by reference herein. Various suitable ways in which theteachings herein may be combined with the teachings of U.S. Pat. App.No. [ATTORNEY DOCKET NO. END8130USNP.0652942] will be apparent to thoseof ordinary skill in the art in view of the teachings herein.

In addition to the foregoing, the teachings herein may be readilycombined with the teachings of U.S. Pat. App. No. [ATTORNEY DOCKET NO.END8130USNP1.0652944], entitled “Surgical Instrument with Removable EndEffector Components,” filed on even date herewith, the disclosure ofwhich is incorporated by reference herein. Various suitable ways inwhich the teachings herein may be combined with the teachings of U.S.Pat. App. No. [ATTORNEY DOCKET NO. END8130USNP1.0652944] will beapparent to those of ordinary skill in the art in view of the teachingsherein.

In addition to the foregoing, the teachings herein may be readilycombined with the teachings of U.S. Pat. App. No. [ATTORNEY DOCKET NO.END8130USNP2.0652948], entitled “Surgical Instrument with SelectivelyActuated Gap-Setting Features for End Effector,” filed on even dateherewith, the disclosure of which is incorporated by reference herein.Various suitable ways in which the teachings herein may be combined withthe teachings of U.S. Pat. App. No. [ATTORNEY DOCKET NO.END8130USNP2.0652948] will be apparent to those of ordinary skill in theart in view of the teachings herein.

In addition to the foregoing, the teachings herein may be readilycombined with the teachings of U.S. Pat. App. No. [ATTORNEY DOCKET NO.END8130USNP4.0652946], entitled “Surgical Instrument with RemovablePortion to Facilitate Cleaning,” filed on even date herewith, thedisclosure of which is incorporated by reference herein. Varioussuitable ways in which the teachings herein may be combined with theteachings of U.S. Pat. App. No. [ATTORNEY DOCKET NO.END8130USNP4.0652946] will be apparent to those of ordinary skill in theart in view of the teachings herein.

It should also be understood that any ranges of values referred toherein should be read to include the upper and lower boundaries of suchranges. For instance, a range expressed as ranging “betweenapproximately 1.0 inches and approximately 1.5 inches” should be read toinclude approximately 1.0 inches and approximately 1.5 inches, inaddition to including the values between those upper and lowerboundaries.

It should be appreciated that any patent, publication, or otherdisclosure material, in whole or in part, that is said to beincorporated by reference herein is incorporated herein only to theextent that the incorporated material does not conflict with existingdefinitions, statements, or other disclosure material set forth in thisdisclosure. As such, and to the extent necessary, the disclosure asexplicitly set forth herein supersedes any conflicting materialincorporated herein by reference. Any material, or portion thereof, thatis said to be incorporated by reference herein, but which conflicts withexisting definitions, statements, or other disclosure material set forthherein will only be incorporated to the extent that no conflict arisesbetween that incorporated material and the existing disclosure material.

Versions of the devices described above may have application inconventional medical treatments and procedures conducted by a medicalprofessional, as well as application in robotic-assisted medicaltreatments and procedures. By way of example only, various teachingsherein may be readily incorporated into a robotic surgical system suchas the DAVINCI™ system by Intuitive Surgical, Inc., of Sunnyvale, Calif.Similarly, those of ordinary skill in the art will recognize thatvarious teachings herein may be readily combined with various teachingsof U.S. Pat. No. 6,783,524, entitled “Robotic Surgical Tool withUltrasound Cauterizing and Cutting Instrument,” published Aug. 31, 2004,the disclosure of which is incorporated by reference herein.

Versions described above may be designed to be disposed of after asingle use, or they can be designed to be used multiple times. Versionsmay, in either or both cases, be reconditioned for reuse after at leastone use. Reconditioning may include any combination of the steps ofdisassembly of the device, followed by cleaning or replacement ofparticular pieces, and subsequent reassembly. In particular, someversions of the device may be disassembled, and any number of theparticular pieces or parts of the device may be selectively replaced orremoved in any combination. Upon cleaning and/or replacement ofparticular parts, some versions of the device may be reassembled forsubsequent use either at a reconditioning facility, or by an operatorimmediately prior to a procedure. Those skilled in the art willappreciate that reconditioning of a device may utilize a variety oftechniques for disassembly, cleaning/replacement, and reassembly. Use ofsuch techniques, and the resulting reconditioned device, are all withinthe scope of the present application.

By way of example only, versions described herein may be sterilizedbefore and/or after a procedure. In one sterilization technique, thedevice is placed in a closed and sealed container, such as a plastic orTYVEK bag. The container and device may then be placed in a field ofradiation that can penetrate the container, such as gamma radiation,x-rays, or high-energy electrons. The radiation may kill bacteria on thedevice and in the container. The sterilized device may then be stored inthe sterile container for later use. A device may also be sterilizedusing any other technique known in the art, including but not limited tobeta or gamma radiation, ethylene oxide, or steam.

Having shown and described various embodiments of the present invention,further adaptations of the methods and systems described herein may beaccomplished by appropriate modifications by one of ordinary skill inthe art without departing from the scope of the present invention.Several of such potential modifications have been mentioned, and otherswill be apparent to those skilled in the art. For instance, theexamples, embodiments, geometrics, materials, dimensions, ratios, steps,and the like discussed above are illustrative and are not required.Accordingly, the scope of the present invention should be considered interms of the following claims and is understood not to be limited to thedetails of structure and operation shown and described in thespecification and drawings.

I/We claim:
 1. A surgical instrument, comprising: (a) an end effector,including: (i) an ultrasonic blade, (ii) a clamp arm configured to moverelative to the ultrasonic blade from an opened position toward a closedposition, wherein the ultrasonic blade and the clamp arm are configuredto receive tissue in the opened position, wherein the clamp arm isconfigured to clamp tissue against the ultrasonic blade in the closedposition, (iii) a first electrode operably connected with the clamp arm,and (iv) a second electrode associated with the ultrasonic blade,wherein the electrodes are operable to apply bipolar radiofrequency (RF)energy to tissue captured in the end effector; (b) a clamp arm actuatoroperatively connected to the clamp arm and configured to selectivelydirect the clamp arm respectively from the opened position toward theclosed position; (c) a first button operable to activate the ultrasonicblade to thereby provide a cutting and sealing mode at the end effector;and (d) a second button operable to activate the electrodes to therebyprovide a spot coagulation mode at the end effector.
 2. The surgicalinstrument of claim 1, further comprising a shaft assembly projectingproximally from the end effector and including an acoustic waveguideoperatively connected to the ultrasonic blade, wherein the acousticwaveguide is configured to connect to an ultrasonic transducer.
 3. Thesurgical instrument of claim 2, further comprising a body projectingproximally from the shaft assembly.
 4. The surgical instrument of claim3, wherein the first and second buttons are located on the body.
 5. Thesurgical instrument of claim 3, wherein the first button is located onthe body, wherein the first button transversely extends from the bodytoward the clamp arm actuator.
 6. The surgical instrument of claim 5,wherein the first button is configured to be actuated as the clamp armactuator moves toward the body and engages against the first button. 7.The surgical instrument of claim 6, wherein the clamp arm actuator has aproximal end, wherein the body has a proximal end, wherein the proximalend of the actuator is movable toward the proximal end of the body tothereby urge the clamp arm toward the closed position, wherein the firstbutton is located at the proximal end of the body, wherein the firstbutton is configured to be actuated by the proximal end of the clamp armactuator.
 8. The surgical instrument of claim 3, wherein the secondbutton is located distally relative to the first button.
 9. The surgicalinstrument of claim 1, wherein the clamp arm comprises a top pad and abottom pad, wherein the bottom pad is located between the top pad andthe ultrasonic blade.
 10. The surgical instrument of claim 9, whereinthe top pad and the bottom pad are spaced apart within the clamp arm.11. The surgical instrument of claim 10, wherein the first electrode isincluded with the top pad.
 12. The surgical instrument of claim 11,further comprising a third electrode included with the bottom pad,wherein the third electrode has opposite polarity of the firstelectrode.
 13. The surgical instrument of claim 12, wherein the thirdelectrode is a radio frequency (RF) electrode.
 14. The surgicalinstrument of claim 1, wherein the ultrasonic blade defines the secondelectrode.
 15. The surgical instrument of claim 1, the clamp arm furthercomprising a third electrode positioned to proximally face the secondelectrode of the ultrasonic blade.
 16. A surgical instrument,comprising: (a) an end effector, including: (i) an ultrasonic bladeproviding a first electrode, and (ii) a clamp arm configured to moverelative to the ultrasonic blade from an opened position toward anintermediate position and a closed position, wherein the ultrasonicblade and the clamp arm are configured to receive tissue in the openedposition, wherein the clamp arm is configured to clamp tissue againstthe ultrasonic blade in the closed position, wherein the clamp arm isoffset from the ultrasonic blade to define a predetermined gap in theintermediate position between the opened position and the closedposition, wherein the clamp arm includes a second electrode and a thirdelectrode configured to be separately spaced to bias the clamp arm andthe ultrasonic blade to the intermediate position, wherein the first andsecond electrodes have poles opposite of the third electrode, whereinthe second electrode is positioned within the clamp arm actuatorproximal to the ultrasonic blade relative to the third electrode; (b) ashaft assembly projecting proximally from the end effector and includingan acoustic waveguide operatively connected to the ultrasonic blade,wherein the acoustic waveguide is configured to connect to an ultrasonictransducer; (c) a body projecting proximally from the shaft assembly;(d) a clamp arm actuator operatively connected to the clamp arm andconfigured to selectively move relative to the body from an openedconfiguration to a closed configuration to thereby direct the clamp armrespectively from the opened position toward the intermediate positionand the closed position; (e) a first button operable to activate thefirst, second and third electrodes; and (f) a second button configuredto deactivate the first, second and third electrodes when the clamp armactuator is in the closed configuration.
 17. A method of performingcoagulation using a surgical instrument, the method comprising: (a)delivering an ultrasonic energy to an end effector at a first ultrasonicintensity; (b) delivering a radiofrequency (RF) energy to the endeffector at a first RF intensity; (c) detecting a contact of the endeffector with a tissue; and (d) in response to detecting the contact ofthe end effector with the tissue, changing one or both of the firstultrasonic intensity to a second ultrasonic intensity or the first RFintensity to a second RF intensity.
 18. The method of claim 17, furthercomprising: (a) detecting a release of the end effector from the tissue;and (b) upon detecting the release of the end effector from the tissue,changing one or both of the second ultrasonic intensity to the firstultrasonic intensity or the second RF intensity to the first RFintensity.
 19. The method of claim 18, wherein the act of detecting acontact of the end effector with a tissue comprises comparing athreshold impedance value for an RF pulse with an observed impedancevalue for the RF pulse, wherein the contact of the end effector with thetissue exists when the observed impedance value for the RF pulse isbelow the threshold impedance value for the RF pulse.
 20. The method ofclaim 19, wherein the threshold impedance value is set to 4000 ohms.